Download pupillae and ciliary muscle following third-nerve

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CASE REPORT: ABNORMAL INNERVATION OF THE SPHINCTER
PUPILLAE AND CILIARY MUSCLE FOLLOWING
THIRD-NERVE REGENERATION
BY
W. RITCHIE RUSSELL and M. HATFIELD WRIGHT
From the Depar-tmelnt of Neurology, Radcliffe Infirmary, Oxford
(RECEIVED JUNE 16, 1948)
Bender and Fulton (1939) showed that in monkeys,
following regeneration of the sectioned third cranial
nerve, a mass innervation of the muscles supplied
by the third nerve develops. This resulted in
limitation of upward and downward movement of
the eye owing to synkinesis of the antagontist muscle.
Recovery of inward movement was good, but was
associated with pupillary contraction. Ford, Walsh,
and King (1941), and Bender (1945), pointed out
that after regeneration of the ozulo-motor nerve
in man pupillary constriction on convergence may
be one of several synkineses observed, and, as the
pupil is often inactive to light a " pseudo-ArgyllRobertson" pupil phenomenon may appear. It
seems that indiscriminate regeneration through the
scar on the injured nerve leads to this phenomenon,
and Bender reported cases in which the pupil reacted
on contraction of any one or all of the formerly
paralytic muscles. He also described a case in
which there was synkinetic contraction of both the
ciliary muscle and the sphincter pupille in association with eye movement. Schretzenmayr (1947)
studied similar synkinetic movements of the upper
eyelid.
In the following example of this phenomenon
both the sphincter pupille and the ciliary muscle
contract when the eyeball is turned inwards.
Case Report
On July 11, 1944, a bombardier, aged 29, had a severe
motor-cycle accident which caused fracture of the left
parietal bone and base of the skull. There was bleeding
from the left ear. The duration of retrograde amnesia
was about one minute, and of post-traumatic amnesia
ten days.
His physical recovery was satisfactory except for
ocular palsies affecting the left eye. He was reported
during convalescence to have left ptosis; the left pupil
was dilated and inactive; all movements of the left
eyeball were lost except for slight upward and downward
movement. There was analgesia of the left upper lip,
and slight deafness of the left ear.
He was invalided from the service in December, 1944,
and returned to work as a mechanic and driver in
January, 1945. Later he left this work as looking upward made him feel giddy, and for the past year has been
working as a handyman. He complains now (May,
1948) of deafness in the left ear, parnsthesix over the
left cheek, and difficulty in reading. The visual difficulty
appeared to be due to paralysis of accommodation of
the left eye while the right eye " had never been strong."
Examination of the eyes revealed some interesting
abnormalities.
Figs. 1 and 2 illustrate respectively the size of the
pupils in the dark and when exposed to a bright light.
The absence of light reaction in the left pupil is quite
evident. Ocular movements to the left appeared to be
full in both eyes: upward and downward movement of
the left eye were defective (Figs. 5 and 6). On looking
to the right the movement of the left eye was good, but
was associated with well-marked contraction of the pupil.
This is seen in Figs. 3 and 4, Fig. 3 being in the dark and
Fig. 4 in bright light (compare Figs. 1 and 2 respectively).
A similar contraction of the left pupil occurred on
convergence, as is seen in Fig. 7 (photograph by flash in
the dark).
Further, not only was the sphincter pupillx made to
contract by deviating the left eye to the right, but also
the ciliary muscle was thrown into activity. Visual acuity
in the left eye was full at six metres (6/6), but owing to
paralysis of accommodation the near vision of the left
eye was reduced to J 12. However, when the Jager type
was held to the right so that the left eye turned inwards,
the near vision improved to J 1, clearly indicating that
this inward movement of the eye caused contraction of
the ciliary muscle.
Ophthalmological Examination.-Ophthalmological examination revealed the following:
Right Eye.-This eye showed no abnormality apart
from a refractive error; he had never used correction
for this eye. Visual acuity (unaided) was Snellen 6/60;
corrected -35/-f- 50, 1 100 it was Snellen 6/18, Jxger 4.
288
.
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THIRD-NERVE REGENERATION
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290
W. RITCHIE RUSSELL AND M. HATFIELD WRIGHT
Left Eye.-There was no ptosis; the conjunctiva,
anterior chamber, media, and fundi were normal.
The left pupil was larger than the right, and showed no
reaction to direct or consensual light. There was a
sluggish contraction on convergence. The left pupil
contracted briskly on turning the eye 30° to the right
(inwards), and dilated on turning the eye to the left.
Visual acuity lookinig straig>ht ahead (unaided) was
I1 .0
Snellen 6/5, Jeger, less than 12. Retinoscopy
1-10
Visuial acuity onl lookinlg 30' to the right (unaided) was
-1 0
Snellen 6/24, Jeger 1. Retinoscopy:--
Looking straight ahead
34 cm.
. .
Looking 20' (approx.) to the
right (inwards)
22 cim.
Looking 30° (approx.) to the
right (inwards)
14 cim.
Looking 20' (approx.) to the
left (outwards)
49
..
..
cornea,
I-10
Extrinlsic Oculal Movemenits.-There was limitation of
the upward and downward movement of the left eye.
The Hess diplopia chart suggested paresis of the left
inferior oblique, inferior rectus, superior oblique, and
superior rectus muscles.
Intrinisic Ocular Move,nenits.-Accommodation
measured by the Livingstone Gauge was as follows:
as
c m.
Discussion
These findings illustrate clearly the abnormal
regeneration of the oculo-motor nerve with mass
innervation of the muscles supplied. PreviouLs
attempts to give the patient reading vision had been
directed towards correcting the refractive error in
his " lazy " right eye. A plus lens provided for the
left
eye
enabled him to read with comfort.
REFERENCES
Bender, M. B., and Fulton, J. F. (1939). J. Neurol.
Psychiat., 2, 285.
(1945). Ar-ch. Nelilol. Psychiat., Chicqago, 53, 418.
Ford, F. R., Walsh, F. B., and King, A. (1941). Bull.
Joh/is Hopk. Hosp., 68, 309.
Schretzenmayr, V. (1947). Deut. zeit. Nerventh., 158, 43.
-
Downloaded from http://jnnp.bmj.com/ on March 3, 2016 - Published by group.bmj.com
CASE REPORT: ABNORMAL
INNERVATION OF THE
SPHINCTER PUPILLÆ AND
CILIARY MUSCLE FOLLOWING
THIRD-NERVE REGENERATION
W. Ritchie Russell and M. Hatfield Wright
J Neurol Neurosurg Psychiatry 1948 11: 288-290
doi: 10.1136/jnnp.11.4.288
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